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Archived: Claremont Hospital

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Inspection report

Date of Inspection: 4 January 2013
Date of Publication: 1 February 2013
Inspection Report published 1 February 2013 PDF | 82.68 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We carried out a visit on 4 January 2013, observed how people were being cared for, talked with people who use the service and talked with carers and / or family members. We talked with staff.

Our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

Reasons for our judgement

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We were informed by patients that they had received calls from staff from the hospital following discharge to check their progress and inquired about their welfare. They also said they were given a short questionnaire at the hospital to complete.

Patients said if they found the care and treatment unsatisfactory they would not be returning to the hospital. One patient said, “I will let the directors know if I am less than happy. I am very satisfied with the treatment.” Patients told us they had looked up the information on the website about the success rate of the interventions from the surgeons and also sought information about the hospital before seeking treatment.

Staff said they had staff meetings where they discussed matters for improvement and also what was going well. They said this was reported to the governance meetings by their managers and action was taken. Staff said they had received satisfaction questionnaires from the hospital management in the past.

We saw the systems used by the managers for gathering, recording and evaluating information about the quality and safety of treatment and care the service provided. We had access to a variety of audits carried out at the hospital and the outcomes. We were told by the departmental managers that all the information was regularly fed into the hospital governance committee to help with future plans. We noted several projects and improvements had taken place through the governance committee to promote quality. For example the documentation, staff supervision and patient information format were some.

The registered manager shared with us the system they had in place to continuously identify, analyse and review risks, adverse events, incidents, errors and near misses. Information about this had been used to develop solutions and risk reduction actions to ensure patients and staff were safe. We saw evidence that learning from incidents and investigations had taken place and appropriate changes had been implemented. The registered manager told us that all staff were informed through their departmental managers when changes were made due to an adverse event so that such events could be prevented. They also told us staff who were directly involved were appropriately supported and supervised so that they were given an opportunity to learn from the incident.